Inaccurate MDS Assessment and Documentation for Resident Functional Status
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for one resident, as required by federal regulations. The resident, who had diagnoses including dementia and rheumatoid arthritis, was documented in the quarterly MDS as having no impairment in range of motion for upper and lower extremities. However, direct observations and staff interviews revealed that the resident's lower extremities were sometimes flexed while seated, and the right hand was often in a closed position, requiring staff assistance to open. Further assessments by therapy staff confirmed limited range of motion in the resident's right wrist due to osteoarthritis, which was also supported by a clinical record and X-ray. Despite these findings, the MDS did not accurately reflect the resident's actual physical limitations. Additionally, the MDS indicated that the resident utilized a manual wheelchair and was dependent on chair mobility. Observations and staff interviews, however, showed that the resident primarily used a Broda chair, which is not classified as a manual wheelchair according to the RAI manual. Documentation in the clinical record and therapy notes confirmed the use of the Broda chair. The facility was unable to provide documentation to support the MDS coding, and the Regional Reimbursement Specialist could not confirm the accuracy of the MDS. These discrepancies demonstrate that the facility did not ensure the MDS assessment accurately reflected the resident's status, as required.